Abstracts Vol. 1 [International Conference on AIDS (11th: 1996: Vancouver, Canada)]

Tu.B.2186 -Tu.B.2190

Tuesday July 9, 1996

(p=0.035 by t test). Fwive deaths unrelated to CMV disease occurred in gr. A cduringr followup (at 4, 6, 7. 8 and 12 rronths) without evidence of retinal disease progression.
Conclusion: Incomplete responses and eady relapses were reported with systemicTrr eatment ofrAIDS-related CMV/ retinitis, due to unsatisfactory local drug levels, and/or to drtug
resista inces. Cobined (irtrivitreous + systemeic) treatment seems to be characterized by
early tnd long- Iasting respo,se, with longer progression-free interval if compared to sy--
temic treatment. Prospe tie, controlled studies are needed in order to better compare
these regimens.
Baibiano Rosanna, Ospedale LWile di Asti,ia Botallo 4 - 14100 ASTI (Italy) Telephone: [phone]'0. Fax: 39- '1 -19)1338. E mail: infettdoasi.shinyt
Tu.B.2186
PROLONGED SURVIVAL OF AN AIDS PATIENT WITH CYTOMEGALOVIRUS
COLONIC VASCULITIS TREATED WITH GANCICLOVIR
ones Sharon. Li.ra, E.., Kaltnen H.P. Smith, M.LU. Mercer University School of Medicine,
Macrn, Georg,, UJSA
Objective: To descr nhe the li c al courst e of patient with CMV colonic vasculitis treated
with continuous iil r ov.
Methods: Chart review cf i patient with CMV vasculitis treated with continuous ganciclovir
and a review of the i tertitue concerning l ongevity of patients with this diagnosis.
Results: The patient was a 35 year old white male with AIDS who was admitted for
abdominal pain and diarrheI. Physical exam revealed abdominal tenderness and a right
lower quadrant mass thai ai s confir red by a computerized tomographic (CT) study of
this area. A right hemocokctomry was performed.-The resected specimen revealed CMV
vasculitis. He was irtially treated with a 14 day regimen of IV ganciclovir with improvement
of his abdomina pa in and,i rrhea. li symptoms, however, reoccurred five weeks later A
repeat CT scan of hs abomen revealed diffuse i rregular mucosal thickening in the remainder of his colon. H ie was restarted on ganciclovir with mprovement of his symptoms and a
decrease in the bowel i! thi ckening on repeat CT scan. His IV ganciclovir was continued
until the ninth month folowing his initial presentation.With recurrence of his symptoms at
this time, the patient iihose to foreo further therapy and died I month later.
Conclusion: Survival with A LS related CMV colonic vasculitis has been limited to usually
less than one month foll>wng dagnoI ss. We report that prolonged survival may be possible
with c)tinuou s intravenous ancicovr
Sharon Jones, M.[., Medic al c1enter of Central Georgia PO. Box 6000, Macon, Georgia
31208 Telephone: [phone]
Tu.B.2187
GANCICLOVIR (GCV)-REFRACTORY CYTOMEGALOVIRUS ENCEPHALITIS (CMVE)
IN AIDS WITH PROLONGED RESPONSE TO FOSCARNET (FOSC)
Sander s ohnW., AIDS Clinical Trials Subunit. Medical University of South Carolina,
Chark ston, South Caroli, iUJSA.
Objective: CMLVF in AIDS -Ied ur vwal of 5 weeks. It is rarely diagnosed or treated due to its nonspecif nical presentation rand the lack of an accurate non-invasive diagnostic test. We report a cadeveloping, durin g GCV induction therapy for CMV pneumoniti,, diainose b,y gadii manetic resonance imaginrig (MR) with a prolonged
response (9 mot) to I c one.
Methods: Case retport,,;t;Iog and radigraphic indi ngs, literature review.
Case Report: A 38 year ll m in with AIDS and a CD4 count of 4 /mrn3 presented with
cough, dyspnea iand fever 8 A chest xray (CXR) showed increased interstitial markings.
Bronclioalveolar Isva gc faied to show pneuIaicyst Is, fungi, or mycobactena.Transbronchial
biopsies (x5) showed man i, cytopsn,ic and intranucear inclusions in respiratory epithelial
and vasculatr iendothel al ells that stained irmunrocytochemically for CMV. GCV 5 mg/kg IV
q 12 hrs.was begun. Dyspnrandii CXR finding, resolved in1 4 days.At this time confusion,
ataxia, pathy, diplopi, a, gi nglt intrinuc lear iopthalmoplegia developed. No CMV retinitis
was present. Coriputerized tomoiraphy (C T) showed "diffuse vague white matter and
deep gray matter chare,". Cerebrospinal fluid showed 6 lymphocytes per mm3, protein
137 rmg/dl, and eti p cr is, Crptoc occal antigen, and CMV polymerase chain reaction
tests. A/n MR sho we 'ex nr" e diffuse pe riventricular and aqueductal signal abnormalities
with enhincerren t icon i with por reports of CMVE2. Brain biopsy was declined.
Fosc 60 rr/kg IV i( its h, ubstiti ited for GI( Confusion and diplopa improved on
da I of Fos(. No.nl rl mnntl status ird riinimlataxia were present on day 19. MR 2
weeks later showed "si rfi it l decr eae in the size of the previous lesions without
enhancemenl".t N i rniorths later he h is a normal miental status, minimal ataxia, slight latera gaze nys tagmus andri ot,ie CV retil lesion on Fosc 90 mrg/kg/day
Conclusions: (iMV i/may ve typical MR findings justifying empiric therapy in the absence
of other findings, with v r Irnow LD4 counts. MR may be more accurate than CT for the
presurnpvr tdiagriosof MVE. C(_V refractory CMVE has responded to combined GCV
and Fosc- t, bu this I the fir repor of prolonged response to Fosc alone.The response of
CMV t pneumonitis to (( V n thI s case suggests tht the benefit of Fosc for CMVE may nriot
be du to L.MV resstar,. to (_CV A ndomized trial of osc vs. GCV for CMVE FIs war
ii ated.
John VI. Saders, MD, M I 0 _3 Frvers Dr., Cfta leston, SC, 29412, USA Telephone: [phone], F-x: 80isv 72 a. 0, E ril J h W Sirndersi osmtgpw.musc.edu
Tu.B.2 188
PREDICTIVE FACTORS FOR DEVELOPING CYTOMEGALOVIRUS DISEASE AMONG
AIDS PATIENTS IN A TRIAL OF ORAL GANCICLOVIR PROPHYLAXIS
Fijhaey, Brosga t C'I i, imn D'*' Lou s A.', Craig Cr*, Ei-Sadr W" i*, the
Terry Beirn tommunitil eas t grams Iot fthnal Research on AIDS (CPCRA). tRichr ond
AIDS onsortiurVA UCA; 'Srn F,ncisco Community Consortium, CA USA; **U
Minne'ott, MN, * ' sa st. tI ' Harlem AIDSTit Group, NY USA
Objective: To compare fa oras predIctie of developreg cytomegamovirus (CMV) disease
among patients pnrt ipat r, i a clinica! trial of CMV prophylaxis.
Methods: Analsis was on ucted on dia from all particpants in CPCRA 023,"A
Randomized P!,ebo Cont oledTral of the Safety and Efficacy of Oral Gancicovir for
Prophylaxir s of dV Retind,nd G istrintestinl Mucosal Disease in HIV infected individuals
with Sver e Imaumasupr,, n".91 patcents coinfected with HIV and CMV, with CD4 <

100, were randomized to o ral ganciciovir vs. placebo (2:1).The study was terminated as
planned with r'eda, ' )low-up of 15 months.The study did not demonstrate a benefit for
oral ganciclovi r rvett, cy CMV disease. Patient baseline characteristics included: mean
age 39, 95% mrale: ' vwhite; 19% Afican-American. HIV risk factors: homosexual/bisexual
86%, male-femrnre exI i%i i[)U 12%. Statistical analysis was performed using multivariate
Cox proportional hazards regression.Time-varying covariates were used in analysis of the
time to CMV disease for AIDS related opportunistic diseases (ODs).
Results: 156/994 (16%) patients developed CMV disease. For baseline characteristics, significant hazard ratios (HR) for CMV disease included African-American ethnicity (vs white)
(HR-0.4, p=0.002), CD4 < 25 (vs < 50) (HR - 2.34, p < 0.001), Kaposi sarcoma (KS)
(HR= 1.79, p=0.006). disseminated M. avium (MAC) (HR-= I1.98, p=0.05), and age> 40
(HR= 1.46,p=0.03) Incorpating data colected during the study showed that progression of
disease, as indicated by development of an OD, was associated with increased risk of subsequent CMV disease.The ODs with the most significant risk included: MAC (HR=2.95,
p=0.0001), KS (HR=2.38,p=0.0001) and thrush (HR= 1.88,p=0.0008). Median days to CMV
disease after ODs ranged from 98 to 21 I days for all ODs except wasting For wasting,
median time was 32 days.
Conclusion: When considering baseline characteristics only Africian-American ethnicity was
associated with a signicicantly lower risk of CMV disease, and prior MAC and KS with a
higher risk. Regression analyses incorpating follow up data showed that the development of
ODs, particularly MAC and KS, was associated with increased risk of subsequent CMV disease.
Evelyn Fisher, Sanger Hall, Room 7082, 1101 East Marshall Street, Ri chmondVA 232 19
USA,Tel: [phone] II Fax: [phone]
Tu.B.2189
CMV CULTURE RESULTS AND CLINICAL OUTCOME IN AIDS PATIENTS WITH CMV
RETINITIS TREATED WITH EITHER FOSCARNET OR GANCICLOVIR.
Jacobson MA*+, Drew WL**, Dunn James Philip*, Feinberg J*+, Holbrook J*, Martin B*,
Min N*, Murphy R+.
*For the Studies of Ocular Complications of AIDS (SOCA) Research Group* (Baltimore,
MD, USA) and the AIDS Chlnical Trial Group (ACTG)+(Bethesda, MD, USA); 5*UCSF Mt.
Zion Medical Center (San Francisco, CA, USA)
Objective: To determine the prevalence of positive blood and urine cultures for
cytomegalovirus (CMV) at baseline and during follow-up and to correlate culture results
with clinical outcomes in patients with newly diagnosed CMV retinitis treated with either
foscarnet (FOS) or ganciclovir (GCV)
Methods: CMV blood and urine cultures were obtained from 207 patients enrolled in a
randomized trial comparing FOS and GCV in the treatment of newly diagnosed CMV
retinitis. Specimens were collected at baseline and, as available, at I, 3, and/or 6 months of
follow-up.
Results: 81/1 81 (45%) of evaluable blood cultures and 120/1 69 (71%) of evaluable urine
cultures were positive at baseline. Rates decreased 5- to 10-fold after initiation of either
treatment. However; FOS-assigned patients had a higher rate of positive urine cultures during follow-up (relative rate FOS vs. GCV=3.0 [P<0.00I]). Median survival of patients who
had a positive vs. a negative baseline CMV blood culture was 8.7 vs. 15.2 mos. After adjust
ing for other factors associated with mortality the RR for a positive baseline blood culture
was 1.97 (95% CL: I.19-3.27). Persistently positive blood cultures during treatment were
associated with more rapid progression of retinitis. Baseline positive urine cultures were also
associated with mortality, with an adjusted RR of 2.03 (95% Cl I.09-3.8 I). However, neither
baseline nor follow-up urine cultures were predictive of retinitis progression.
Conclusions: Treatment with either FOS or GCV was associated with clearance of blood
and urine cultures. Positive blood and urine cultures at baseline were both associated with
increased mortality Persistently positive blood cultures were associated with more rapid
retinitis progression.
James P Dunn, M.D., 550 N. Broadway, Suite 700, Baltimore, MD 21205
Tel: [phone], Fax:- [phone]
Tu.B.2190
ASSOCIATION OF CYTOMEGALOVIRUS (CMV) RETINITIS CHARACTERISTICS
WITH DISEASE PROGRESSION AND VISION LOSS
Holbrook, JanetT*, Davis M, Gilpin AK*, Hubbard L--C, Martin B*. *Center for Clinical
Trials,The Johns Hopkins University Baltirmore, MD, USA, t Fundus Photograph Reading
Center, University of Wisconsin, Madison, WI, USA.
Objectives: (I) Identify characteristics of newly diagnosed CMV retinitis that are associated
with retinitis progression or visual loss and (2) determrine if retinitis progression itself is
associated with vision oss
Methods: Data from 224 patients with newly diagnosed retinitis (321 eyes with retinitis)
enrolled in a multicenter clinical trial were analyzed. Fundus photographs were evaluated at
a reading center to characterize newly diagnosed retinitis and, during followup, to assess
retinitis progression (border movement of 750p or appearance of a new lesion)
Associations between progression and retinitis characteristrcs, and between visual acuity loss
and retinitis progression were evaluated using the methods of Kaplan Meier and Cox proportiona hazards.
Results: Progression was observed in 234 (73%) involved eyes 29 (23%) of 125 uninvolved
eyes developed retinitis during followup. In involved eyes, factors associated with progression were size of the lesion (P-.007) and lesion border activity (P=.01 ). Characteristics of
involved eyes associated with retinitis development in a previously uninvolved companion
eye were lesion border activity (P=0.002), greater distance of lesion f-rom the disc (P-.002)
and disc involvement (P-0.003); systemic characteristics associated with development of
retinitis in a previously uninvolved eye were number of inductions (P-.000 I), positive blood
(P-.0002) or urine culture at baseline (P=.009).and longer lime snce AIDS diagnosis
(P-0.04).A decrease in visual acuity to <20/40 was observed in 48% of 252 eyes involved
at enrollment. Factors associated with visual acuity loss were earlier retinitis progression
(P=.002), proximity of lesion to the disc (P-.007), macular involvement (P=0.07) and baseline visual acuity (P-.008)
Conclusions: Smaller lesions surrounded with active borders at diagnosis progressed more
quickly Lesions surrounded with active borders, farther from the disc or involving the disc,

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